When Time is Crucial—The Origin of EMS

May 17-23 is EMS Week—and you know what that means! Or maybe you don’t. If you’ve never had your life or that of a loved one saved by a team of emergency responders—paramedics, emergency department physicians and nurses, and trauma unit surgeons—you may not think too much about the Emergency Medical Services (EMS) system; it’s just there, like electricity or the water supply. We assume that if someone is seriously injured, or having a possible stroke or heart attack, we can call 911, and an ambulance will arrive. Highly trained paramedics will quickly assess the injury or illness, stabilize the patient—binding wounds, starting IV fluids and/or oxygen, performing CPR, administering drugs, or whatever. Then, while speeding to the nearest hospital equipped for that particular emergency, they will communicate with the hospital emergency room, so that the staff there can be ready to treat the patient on arrival. The ambulance crews and the emergency departments are available 24/7 in most communities. The EMS system is in fact an amazing operations network that coordinates emergency transport and care when time is crucial.

The EMS system that we take for granted didn’t exist before the 1970s. If you were badly injured in a traffic accident, for example, or stabbed or shot in a bar fight, there was no 911 system. Instead, someone called the local police dispatcher, who would send out an ambulance from a local hospital, fire department, volunteer service, or funeral home (about half of all ambulances were modified hearses, staffed by off-duty mortuary attendants.) Ambulance attendants typically had some basic first aid training and could stop the bleeding, but little else. If no ambulance was available, the police would load you into a squad car. The main goal was to get you to the nearest hospital as quickly as possible. At the hospital emergency room—often staffed only by a nurse or a medical intern—you waited while calls were made to on-call surgeons and specialists, or to medical residents in the hospital wards. If the hospital was a small one, without the staff to adequately treat you, you might wait many hours to be transferred to a larger medical center. And sometimes, while waiting, you might die.

The current EMS system grew from a convergence of several trends in the late 1960s. The MASH units of World War II and the Korean War had proved that rapid transport and treatment of battle casualties saved lives. Although this system had not been widely applied in civilian medicine, improved medical understanding and treatment of physiological shock was validating the military experience. Meanwhile, cardiopulmonary resuscitation (CPR) was shown to be an effective intervention for heart attacks, and pioneering programs in pre-hospital cardiac care were set up in Belfast, Northern Ireland, and in Miami, New York, Los Angeles, Seattle, and Columbus, Ohio in America. The federal government was also taking an interest in the state of emergency care, as deaths from accidents, especially traffic accidents, increased during the post-war years. The National Research Council (NRC) studied this problem between 1963 and 1966. Its final report, Accidental Death and Disability: the Neglected Disease of Modern Society, noted that the U.S. health care system was poorly prepared to handle an injury epidemic that was the leading cause of death for those between the ages of 1 and 37. Ambulance services varied widely in quality; the vehicles were poorly designed for administering care, and couldn’t communicate with hospitals; and hospital emergency facilities also varied. Even large urban hospitals, which handled the largest volume of trauma cases, often had only rudimentary emergency room staffing and services. (Always regarded as money-losers by hospital administrators, emergency rooms were also increasingly crowded with non-emergency cases from poorer city areas.) The NRC report recommended, among other things, federal funding to extend training for emergency responders, establish standards for ambulances, and improve communications networks. The Highway Safety Act of 1966 empowered the Department of Transportation to fund some of these EMS improvements, and required states to develop regional emergency systems.

The NRC report also recommended that emergency rooms be categorized according to the services they could provide, and that major trauma units be established that could provide complete care—resuscitation, blood transfusion, lab work, radiology, etc., and ready access to operating rooms or intensive care units. In 1966, Cook County Hospital in Chicago became the first to set up such a trauma unit. Resident surgeon David R. Boyd became the unit’s director in 1968, and over the next few years, he and his colleagues refined its operations and talked up the trauma unit concept. They caught the attention of Illinois governor Richard Ogilvie, who asked Boyd to draft a plan for a statewide trauma center system.

The Great Cook County Hospital Group, Chicago. National Library of Medicine #D02335

The plan, written with his colleague Dr. Bruce Flashner, was based on the clinical and organizational experience of the Cook County Hospital Trauma Unit. It would categorize all Illinois hospitals and specifically designate some 40 new trauma centers in a three-tiered system in the 9 state administrative regions. Just as important, it would require a pooling and coordinating of medical resources within each geographic area. From 1971 to 1974 Boyd directed and developed the fledgling program, which subsequently became a model for a nationwide system.

Reprint of “Trauma—A Controllable Disease in the 1980’s” by Dr. D. R. Boyd in the Journal of Trauma, 1980. Courtesy D. R. Boyd

President Ford shakes hands with Dr. David Boyd. Courtesy D. R. Boyd

Congress passed the Emergency Medical Services Systems Act in 1973 to fund the establishment and expansion of regional EMS operations and education. President Ford appointed Boyd as director of the Division of Emergency Medical Services Systems within the Public Health Service in 1974. In this post, Boyd spent nearly a decade working with state and local physicians and officials to establish emergency medical systems according to federal standards. To qualify for federal assistance, EMS systems had to include fifteen components: manpower, training, communications, transportation, facilities, critical care units, public safety agencies, consumer participation, access to care, patient transfer, coordinated patient record keeping, public information and education, review and evaluation, disaster planning, and mutual aid. (This was challenging work, as local hospitals and medical communities were often slow to see the benefits of a cooperative arrangement, and resisted the changes.) By the early 1980s, when the national program was ended by Reagan-era budget cuts, the “emergency experience” of many Americans was vastly improved. We all hope we’ll never need the EMS system and the dedicated folks who make it all work, but this week, take a minute to appreciate it!

Dr. David Boyd is generously donating his papers to the National Library of Medicine’s History of Medicine Division. During this ongoing process he has provided a series of oral history interviews about his career as a trauma surgeon and an EMSS pioneer that informed this article. Dr. Boyd has published over 130 scientific articles on Trauma, Shock and Trauma/EMS Systems including a textbook on EMS Systems.

Susan Speaker, PhD, is Historian for the Digital Manuscripts Program of the History of Medicine Division at the National Library of Medicine.

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5 comments

Interesting summation of the early history. In the 1964-67 time period I was a surgical trainee in the US Public Health Service Hospital in San Francisco. I routinely volunteered to fly with the Coast Guard Helicopter crews on their rescue missions. There was no specific accommodation for a CG EMS crewman so they were happy to have volunteers. They would leave from a peninsular CG helicopter station and pick me up at the hospital and off we would go . It was not an easy time as it was up to me as to what to bring and the injuries were varied. As an avid photographer I have several photos of dramatic rescues etc. After reading your article I realized I was a pioneer EMS personnel. I dont know when actual EMS assigned personnel were on CG helicopters– does anyone???

Thanks for sharing your experiences of the early days of EMS! This highlights another of the emergency services that developed in the U.S. during this era, concurrently with civilian trauma services. I’m not sure when EMS personnel became standard on Coast Guard rescue helicopters, or how military and civilian services were coordinated — I’ll forward the query to Dr. Boyd and post the answer here.

Kudos and National Appreciation are merited by Dr. David Boyd, MD, CM, for his seminal and crucial contributions to American Medicine and indeed to society!
Saul Levine, MD, CM, Professor Emeritus in Psychiatry, UCSD

Many thanks for your comment. Dr. Flashner was indeed a key player in the early years of EMS development; as mentioned in the post, he and Dr. Boyd co-authored the original Illinois trauma center plan that became the basis for the national system. As you’ve noted, he later developed some of the first free-standing urgent care centers. I hope that someday soon, some enterprising medical historian will write a definitive history of emergency care during the second half of the twentieth century, one that can give proper credit to the myriad physicians, surgeons, nurses, and public health officials in the military, and in public, private, or university institutions who conceived and built the system. Alas, it’s difficult to do the subject justice in a short blog post!